Hi. Happy Saturday. Thank you for having me. It's an honor and a privilege to be here. Thank you, Heather, for inviting me. I was asked to speak. I was just like. Okay. Okay. Sorry about that. I was. I was asked to speak about why do people stay? So really I have focused a lot on APP staffing and some on physicians in this talk. I focus mostly on the Emory Critical Care Center as we get started. I don't have disclosures and that slide is not important, but it just said a little bit about me that's already been said. What I wanted to focus on is why we have been able to attract, select, and get folks to stay at our organizations. Also, what I have found to be true is so many times when we're recruiting, a lot of it has to do with really establishing if people know if they want to work in an academic medical center or if they actually don't have a preference. And so the types of organizations I think goes a long way when we're recruiting. And then we're going to go through some unique offerings that can be used that might allow us to better retain our staff by the competition. So what I wanted to focus on is culture, compensation and benefits, hours and schedules, care and concern for diversity, equity, inclusion, well-being, and flexibility and adaptability. So from a cultural perspective, you know, one of the things I have the privilege to do is meet almost all of our physician or APP candidates in the center. And oftentimes, I'll ask if they know or don't know yet. And that's a perfectly acceptable answer if they care to be in an academic medical center. And it's pretty easy to ascertain if someone sort of understands the question. And it's not intended to be a trick question. But many times, you're going to meet people that actually want to help with education and research. And over time, what I've realized is if we don't give people the opportunity to do so, we're not going to be able to retain them. So for example, you know, APPs and physicians are high-ranking professionals. And sometimes, because of our discipline in the ICUs, we can be treated like shift workers and accordingly might not allow enough time to receive mentees or really take the time to go over different things other than rounds with some of the people that we are trying to retain. So I think that becomes a really important part of our culture is really determining if we're going to be an academic medical center, how do we build in work schedules that would honor mentees and not burn people out by asking them to work longer than their shifts? I'm not saying I have a current answer to that dilemma, but I think it's an important one. A lot of times, what I have really appreciated in working in academics is also looking at exit surveys but also talking to people on the interview process is how do we sell that we're a team environment in the ICU? And is it actually believable? We have over 15 ICUs at Emory across six hospital systems. And accordingly, we can't control for the culture in each of those ICUs. And we believe that everyone's functioning as a team and try to address people by their first names, certainly respect and understand what discipline they represent while we're working, but certainly treating them as a team is helpful. We certainly get information. We had a recent well-being survey that really helped us understand that some people do feel valued as a team member and in some units, maybe not so much. So still lots of work to do when you're in a big system. And then to that end is the size of the system causing some bureaucracy and unintended consequences. So let me give you an example. One of the things that we're hearing a lot about from a burnout perspective is how do we offer flexibility? And we'll get that further down into some additional slides. But when we're thinking about 15 ICUs, are we allowed to pilot something in a local ICU such as flexible work hours and not create too much friction if we're not offering it in others until we really understand how to use it and use it productively for, you know, the care of the patient. And so sometimes our size is working against us. The other thing is many times we aren't able to impact local decisions and we have to run things through central offices. So I can often talk to an APP or a physician who doesn't understand why their idea wasn't yet implemented. And we badly would love to honor their idea and yet we don't have the, you know, the authority at a local level to say we absolutely can pilot that new maternity or paternity policy. We typically have to go through our central offices and that can be very frustrating. So even if people want to work in an academic medical center, which is often larger and bureaucratic, they might sometimes lean towards other environments because of the slow way in which we can establish new norms. And then how is the ICU structured in the health system? This is critically important as it relates to job satisfaction, retention, recruitment. Are we aligned as a system? So before the Emory Critical Care Center was established, each of the ICUs operated independent from one another and there wasn't any standardization relative to leadership, but specifically quality. So this graph off to the right is just a demonstration of some quality scorecards we're tracking across those ICUs to try to honor and perpetuate that the same OPPE, FPPE process, the same baseline metrics are had regardless of who's leading those ICUs. And so even in some of our survey data, as I referenced with well-being, people will question if things are being done the same way across all the ICUs. And so this becomes really important that people take pride and feel good about the fact that they can go to any of the units and know that our dedication towards quality is the same regardless of which area they're working in. Many times when we're in a system that has a structured ICU leadership, you're going to have the same staffing ratios. So if you work in a big system and you don't yet have all of the ICUs governed the same way, you might create a whole lot of retention issues if your staffing ratios are incredibly different across each of them. And then the MDAPP partnership certainly goes back to team that we discussed above, which is really making sure that everyone can be treated valuably, respectfully at all times so that that quality is maintained. What we have also learned is how problems are handled and quality and behavioral issues are handled. So for example, if someone brings to us a problem, are we discreet? Are we confidential? Or do folks not trust us? Are there systems in place that they can blindly report things such as an online reporting system, whether that be clinically or behaviorally? One of the things that's especially hard about these types of matters is that let's say you have a poor outcome relative to something that's happened with patient care and you're all looking to figure out what's gone wrong and we start to create a bit of animosity and problems are escalated. We certainly can't always tell somebody what's been done if there was an outcome where someone needs discipline. And so we often need to, as leaders, make sure our workforce knows that we hear problems, we respect their feedback. We can't always give them the outcome that might have happened. For example, when you bring something forward, you can't expect that someone on your team isn't going to be there tomorrow because they may have had a problem. Or maybe when it was investigated, it was multifactorial and there wasn't a specific outcome that needed to be dealt with but many things. So that can, we find, be quite dissatisfying but matters really from a retention and recruitment perspective. Types of ICUs. So the culture really comes down a lot of times to are you doing what you wanted to be doing? Are you working in a training environment? Were you onboarded appropriately as a new grad? So all of these things are impacting our culture relative to recruitment and retention. As I mentioned, I have the privilege of interviewing the APPs that come through and that's probably the number one question is how is our onboarding handled? And how are they going to be measured? And what's the length of time? And so that becomes critically important for our ability to retain is that we've brought them on with grace and with enough mentorship that they'll succeed. Compensation and benefits. I didn't put that as number one, quite frankly, because I often think that culture ends up trumping that. So there was sort of an order to my madness of putting this as number two. You know, one of the things that's really tricky is we don't have excellent benchmark data locally and nationally when we look at APP and physicians, depending on the surveys we're looking at, physicians is a little bit more finite than APPs. But ICU versus non-ICU, outpatient versus inpatient. Let me give you an example. Many times we're working hard to not only hire folks, but also move them into leadership roles. And so we actually have at Emory a differentiating, you know, pay rate for people that are lead APPs or protected time for physician leadership. Many times when we're working with our compensation central offices, they might not actually pause and say, oh, we need to give you the inpatient rate. And so we make mistakes all the time because we have considered that we need to have inpatient and ICU rates at Emory. But every now and again, we haven't actually trained staff to make sure that those things are implemented. So minor things could go into this that are really complicated. But during the pandemic and certainly regularly, we were challenged a lot with how much are we paying people? Should that be higher? Should that be lower? What should the shifts rate be? And so looking at this more than once a year became critically important. I don't know how many of you, I suspect all, had to work through contract labor during the pandemic and potentially still doing that. But the marketplace became so competitive that we actually had to, you know, rely on our chief APP to get local rates because our HR teams just couldn't keep pace with what was happening. And it's important that you have that, you know, even if it's anecdotal, to really be able to respond to pay rate increases and things that are happening in the marketplace to make sure we're competitive. One of the things that we also see is just unique benefits. Sometimes people are, in fact, looking for compensation. Other times, they're really interested in how much PTO they're going to get or if we can offer a sign-on bonus because they're looking to make a purchase to a home or something to that effect. So what we have found is that there's no right recipe for recruiting, you know, staff. And many times we're going to ask our recruiters to understand what would it take to get them to come to Emory or to the organization you all are at. And so it can be very person-specific. Many of us in academic medical centers are able to offer some tuition remission. This is complex. I don't know if you all have this in your area, but academic medical centers are often all different and some of them are employing APPs or staff on the university side and some aren't. And so that tuition remission benefit becomes incredibly volatile depending on how your organization is set up. We have had lots of questions for is tuition remission similar to our local healthcare competitor or is it similar to people that are actually working for the university that often get, you know, paid credit hours each semester. So all of these things become important for recruitment and retention. The retirement match we have found can be a bit more competitive than some of our community partners. So that can be a selling point for us as well. One of the things we're grappling with is tiers of experience. So for example, we currently don't have a tier of experience greater than five years, but many of our most senior staff have more than five years' experience, and we need to reward them accordingly to keep them. And so we have so much more work to do as it relates to making sure we keep this competitive edge. You know, paid time off, is it competitive? Is it an easy process? Let me give you an example. Requesting time off isn't complicated, but getting approval for it is. Not every unit is governed by the same logic. Are people taking turns with each holiday year over year? Short and long-term care options. So I talked to someone very recently that actually left a local community hospital because they didn't offer maternity or paternity, and their short-term disability policy didn't actually pay very competitively, and so they weren't, you know, finding it easy to start a family. And so even that level of discrete discussion with a recruiter or with our staff can become critically important to recruitment and retention. What I have found really interesting as I have worked more and more with people that are in shift-based professions like ICUs is this clocking in and out process. So for APPs and physicians, the expectation is that you have received high levels of education whereby you wouldn't be treated that you were, you know, going to work late or not on time, and yet we have these clocking in hours and processes that can drive people crazy. Some folks just do this with absolutely no question, and others, this can be an irritant. So we have found that even things like this can be frustrating to our staff. And then are the job families with the fine staff progression expectations clear? One of the things we found, not at all trying to make us look bad, but we learned from our mistakes. So we had an offer letter that described what happens when you reach your second and third and fourth and fifth year as it relates to both your title and your salary. What we failed to put in but have since corrected is if you have gotten or if you have received several merit increases during that timeframe and you are now at X, you know, range of salary, you no longer would advance to that next tier from a compensation perspective if you already got there through raises and through like a nocturnal differential or a weekend differential. That's pretty deceptive to a new candidate who's expecting to receive a pretty big salary bump in their fifth year. And so these are things that we have to listen to to make sure we can retain our staff. And hopefully I'm not the only one that sort of has those examples. Our schedules work philosophy by profession. So I touched on the clocking in and out already. I'll skip that one. Flexible work schedules. We have seen at our public hospital, so Grady in Atlanta, we have tons of different units, whether they be ICUs or non-ICUs, where four tens are offered, you know, five eighths, three 12-hour shifts. I've seen it work different ways. In our big Emory healthcare system, we actually don't really have a lot of that flexibility. And we're learning through burnout, through well-being initiatives, that people really want that. And we don't actually know what that means yet. So we're really excited to learn more and more about who's done this and done it well and hoping that some of the pilot opportunities we have can determine if we can pull this off. If this will help retention, we want to do it, but we're afraid because it could really impact our coverage. Are there opportunities to pick up shifts at a home unit or other units? There are a lot of people that want to enhance their income, and then there are others that don't want to do that. And so having that opportunity is really an important part of our recruitment and retention. We find that our recruiters will ask us these questions when they're in a negotiation. Is there standardization about PTO? I discussed that a little bit earlier. Equally, we have found that people will say when we ask, you know, what do you want to be doing in five years, many really want to stay on the unit or the area that they're working in. Other times, they may think they do, but later find that they might fit better someplace else, or they bought a house across town and want to move to a different facility. Are we flexible enough to honor that, to retain them in our system? And then the last bullet here, do other clinical team members get treated differently based on the same things? You know, I put this here because in an ICU, you're working across so many different disciplines, and as you all know, not all of the ICUs can be governed by the same thing for a pharmacist versus a respiratory therapist versus an APP, and you name it. We had the privilege of learning recently that there are metrics a pharmacist might be held to that works in the ICU that are incredibly cookie cutter to pharmacy work, but not really helpful for an ICU provider. Can we offer some similar ICU metrics to all of the disciplines in the same area so that even our pharmacists can be retained in a way that's as competitive as we'd like? Obviously, the hot topic for years now and needs to continue is care and concern for diversity, equity, inclusion, and well-being. Are people feeling welcome in the work environment that they're in? We obviously, many organizations now have representatives that will try to do this locally and figure out if we're doing this well and increase initiatives around that. What we have often found is that so many times our workforce doesn't match the patient population. Is that okay? Is that not okay? How do we account for that when we have patients that are going to see so many different care providers that don't represent how they're represented? Do we have surveys set up in our organization to really gather this information? Can we really define what this is like in the ICU versus the larger DEI efforts in our organizations? We have found, we have a DEI committee at Emory and we have really found that they want to do their own surveys so we can get at what is specific in the ICU and really try to address local issues. Are there informal and formal ways to report concerns? We went over that a little bit earlier. The same reporting about maybe behavior or quality hopefully will get at some of these issues as well. Then is the system and local work environment aligned? We all have examples where our organization says something but maybe it doesn't play out locally for us or the reverse could be true. Our local environment is incredibly hospitable to inclusivity but maybe in our organization we espouse to do those things but we don't have a lot of representation at the top that demonstrate a very DEI friendly culture. That's sometimes just how people are hired. Flexibility and adaptability. We've touched on this in some of the other areas. Is there too much standardization that's preventing an ability to respond to the changing workforce requests? The pendulum has swung a bit. We want to standardize what's happening across our units and yet at the same time, how do we make enough flexibility to honor, so we'll just use the example of hours, how do we make sure that hours can be flexible if that's what our workforce is telling us they want? Do recruiters and managers have latitude regarding offer letters and salary and retention opportunities? I mentioned earlier the size of the organization sometimes lends itself to bureaucracy. We have asked and hope to and hope you all can do the same where we have local boundaries that if someone is asking for $5,000 more, a moving bonus or something to that effect, we can honor that locally rather than sending it back through our central responses whereby we have to wait weeks to find out if we can do that or many times we might get rejected because it's not equitable to another service even if it's not an ICU. Those can be real barriers to our recruitment and retention. Are there opportunities to pilot programs that will enhance recruitment? When I had the privilege of working at the critical care center at Emory, they were doing this fantastic refer a friend program whereby people were getting paid if an APP was hired into the center. We're trying to do that again. Our budgets of course are a little bit complicated but that yielded great success. Are you able to offer those things at your institution? We talked about flexible work hours and certainly we are hopeful and continue to learn more about unique opportunities. This is titled odds and ends but it's not at all meant to be less important than the other topics. When Heather was helping me with my slides, she reminded me that one of our biggest areas of uniqueness is the fellowship program. If those of you that have one completely understand what we're talking about but those that don't, highly recommend your organization can consider this where you're constantly recruiting the pipeline of future APPs into the ICUs by honoring an actual formal program. Our exit interview is done. That's critically important. We are recently getting some data that we didn't actually have locally that's helping us really understand some of this. Many times the data is available but actually hasn't been given to us maybe because the N is too small and they're worried that we're going to know exactly who it was or HR is still thinking this data is too discreet or they're using it at a system level and so recently when we asked, we were given it but never actually realized it existed. Does your organization have contract labor? What does your regular workforce think about this? Kind of a controversial discussion at the moment but I think many of us understand that several of us are still working through contract labor issues that began at the pandemic. If maybe you worked with folks that were on contract prior to the pandemic, maybe this isn't new but it certainly was new for us. We had not formally ever used people that didn't regularly work with us and that continuity of care, that level of comfort in our units really has impacted our workforce. How formal is your onboarding and training program? We've recently had the privilege of hiring someone that will lead this across the units and really pay tribute to this so that we can do this more consistently but just better in general. It's yielding some incredible initial excesses. Do you have access to attrition rates? Are there differences among the ICUs versus differences in the system? We don't, we're trying to get at this level of data but I put it on here just because I think this will really help you understand your retention locally. And how often are your staffing ratios evaluated? Is this done with feedback from the units? I think this can be a sensitive topic. I know that in different specialties, the staffing ratio might warrant something. Equally, if you're practicing at the top of your license, that could mean something different depending on the nursing complement or, you know, if a unit is downstaffed across any of the disciplines, we find that many of the physicians and APPs are making up the gaps and so this we see impact recruitment and retention as well. So, so many things to balance when we're trying to look at how we recruit and retain. Some best practices as we wrap up this particular part, simple clear compensation plans with tiers for advancement and opportunities for incentive on metrics that can be managed locally obviously seems like a pretty easy recipe for success and it's just, do we have the latitude to do that? Flexible schedules, fellowship residency programs for recruitment, recruitment and retention bonuses and then onboarding and training, just can't say enough about those things. I know that people enjoy pictures, so we included some pictures from our teams here and one at the bottom is an actual, you know, training that the group was doing. Another was an external event that we host, a 5K where people come out and get to know the care providers better and it's really focused on staff and to some extent some of the patient families. And then of course on the top left is a wonderful patient story of a team. Thank you very much.

recruitment

retention

healthcare organizations

Emory

compensation

diversity